Loading...
108 APT#B12 Notification of Deleading 1999 sob Department of Public Health/Department Of Labor 11 Industries NOTIFICATION OF DELEADING WORK FILE NUMBER ALL sections of this for nest be completed in order to comply with the notification requirements of M.G.L.C. 111 § 197, 454 CM 22.00 and 105 CMR 460.000 as most recently amended Contractor performing ^project \��\NN ,v License#�\y Exp. Date\-a.`S-OQ) Lead Paint Inspector Awn? hwe-St License i Nala‘k PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low- risk deleading work, complete the following ): Property Owner Agent(s) Address NOV-2-24.99 Telephone Number I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations, 105 Cia 460.175, for owner/agent Low-risk abate ant and containment. 1 further certify that 1 or ay agent witL be performing the +-following tow-risk activities (1 have circled all that apply): applying liquid encapsulent capping baseboards removing doors, cabinet doors, shutters applying exterior vinyl siding covering surfaces I certify that all the information contained in this knowledge and belief. ication is true and correct to the best of my Date: Signed: ADDRESS OP PROJECT[ \\ , Q� Street Address \� Apt. Number IVhC\St ��On zip Ct\ct PropertyOwner }�\ ��p Address a-t- C \-\A\ ,W`, Telephone Number ���-lea - aa5a Deleading Method: Wet/Dry Scraping Demolition Heat Gun Caustics Other No "\o..\ ,‘\l.A Liquid Encapsulant Replacement If "Other" selected, please explain Check one: dwelling is multi-family Y single-family other Page 2 of 2 Start Date \\- 74.S\- CVQ1 Completion date \\ -aC-1Zkq When will work be done: am1t c pn4AC{Specify times on site) Weekends? \lp Project Supervisor NameVNEVAVN NAT) License/ \4h1 Exp. Date\ -GG Workman's Compensation Policy\\Number C—Sti eY1c%1t \Q Carrier >,J In Case of Emergency Contact: *dv\�. .y (Contractor's Representative) -:\b1t, In accordance with Massachusetts General Laws C. 111 4197, 454 CMR 22.00 and 105 OM 460.000, notice of the date and methad(s) of removal or covering of paint, plaster or other accessible materials containing dangerous levels of lead is to be provided and net be received by the following persons, at least ten business days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXED. 1. Department of Labor 6 Industries, Division of Asbestos and Lead Enforcement 100 Cartridge Street, Roam 1106, Boston, MA 02202 FAX: (617)727-7568 2. Director, Childhood Lead Poisoning Prevention Program1 5� - Q,y\CZI/ Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617) 96 •6931 (617) 522-8735 3. Occupants of dwelling unit 4. All other occupants of the residential premises, if any 5. Local Board of Health/Code Enforcement Agency - 6. Massachusetts Historical Commission (if premises are listed on the State Register of Historic 220 Morrissey Blvd. Places, this notification mat be fade upon receipt of an Boston, MA 02202 Order To Correct Violations or at least 30 days prior to FAX: (617)727.5128 Initiating preventive deleading) DELEADINO CONTRACTOR: The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth of Massachusetts Deleading regulations, 454 CNR 22.00, antl-lead Poisoning Prevention and Control Regulations, 105 CNA 460.000, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. Date \lo.4e-te C \\n \‘‘k44 Signed *1a4 `/ t". Company Name: \e`ev\S. C. - Ne& Address: .� c nc�1�0a�A cs� \\'` c4. Telephone Telephone Number: Si\cam-�a-1- \\Drti:. NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED - INCOMPLETE NOTIFICATIONS WILL NOT SE ACCEPTED AND WILL HE RETURNED BY D.L.I.